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Biomedical subjects

B Fowble

Publications and source records attributed to B Fowble.

At least 19 recordsLinked to original sources
PubMed1998

The presence of proliferative breast disease with atypia does not significantly influence outcome in early-stage invasive breast cancer treated with conservative surgery and radiation.

PURPOSE: To evaluate the influence of the benign background breast-tissue change of atypical hyperplasia (AH) on outcome in patients with early-stage invasive breast cancer treated with conservative surgery and radiation. MATERIALS AND METHODS: Four hundred and sixty women with Stage I--II breast cancer treated with conservative surgery and radiation from 1982-1994 had pathologic assessment of their background adjacent benign breast tissue. The median follow-up was 5.6 years (range 0.1-15). The median age was 55 years (range 24-88). Of these, 23% had positive axillary nodes; 25% received adjuvant chemotherapy (CMF or CAF) with (9%) or without (17%) tamoxifen. Of the total, 24% received adjuvant tamoxifen alone. The patients were divided into 2 groups: 131 patients with atypical hyperplasia (ductal, 99 patients; lobular, 20 pts; and type not specified, 12 pts), and 329 patients with no proliferative changes or proliferative changes without atypia. RESULT: A statistically significant difference was observed between the 2 groups for method of detection, primary tumor size, presence of lobular carcinoma in situ (LCIS), pathologic nodal status, region(s) treated with radiation, and type of adjuvant therapy. Patients with atypical hyperplasia (AH) had smaller primary tumors (T1 80% vs. 70%) more often detected solely by mammography (51% vs. 36%) with negative axillary nodes (87% vs. 73%) and radiation treatment to the breast only (93% vs. 78%). LCIS was observed in 9% of the patients with AH and 3% of those without AH. Patients with AH more often received tamoxifen alone (32% vs. 21%), rather than chemotherapy (15% vs. 29%). There were no statistically significant differences between the 2 groups for race, age, menopausal status, family history, histology, histologic subtype DCIS when present, the presence or absence of an extensive intraductal component, final margin status, estrogen or progesterone receptor status, use of re-excision, or total radiation dose to the primary. The 5- and 10-year actuarial ipsilateral breast tumor recurrence rates were 2% and 12% for patients with AH and 4% and 8% for those without AH (p=0.44). Younger women or those with a positive family history of breast cancer with AH did not have an increased rate of breast failure when compared to similar patients without AH. There were no significant differences in the 5- and 10-year actuarial rates of distant metastases (AH 5- and 10-year 7% and 7%, no AH 5- and 10-year 8% and 16%,p=0.31), regional node recurrence (AH 1% and 1%, no AH 1% and 1%,p=0.71), contralateral breast cancer (AH 3% and 3%, no AH 3% and 8%,p=0.71), overall survival (AH 95% and 86%, no AH 95% and 89%, p=0.79), or cause-specific survival (AH 98% and 95%, no AH 96% and 91%,p=0.27). Subset analysis for ipsilateral breast tumor recurrence, distant metastases, overall, and cause-specific survival for T1 vs. T2 tumors and path node-negative vs. path node-positive patients revealed no significant differences between the 2 groups. CONCLUSION: AH was not associated with an increased risk of ipsilateral breast tumor recurrence or contralateral breast cancer in this study of patients with invasive breast cancer treated with conservative surgery and radiation. Therefore, the presence of proliferative changes with atypia in background benign breast tissue should not be a contraindication to breast-conservation therapy.

Adult↗
PubMed1998

Lung and heart dose volume analyses with CT simulator in radiation treatment of breast cancer.

PURPOSE: Radiation pneumonitis and cardiac effects are directly related to the irradiated lung and heart volumes in the treatment fields. The central lung distance (CLD) from a tangential breast radiograph is shown to be a significant indicator of ipsilateral irradiated lung volume. Retrospective analysis of the pattern of dose volume of lung and heart with actual volume data from a CT simulator in the treatment of breast cancer is presented with respect to CLD. METHODS AND MATERIALS: The heart and lung volumes in the tangential treatment fields were analyzed in 108 consecutive cases (52 left and 56 right breast) referred for CT simulation. All patients in this study were immobilized and placed on an inclined breast board in actual treatment setup. Both arms were stretched over head to avoid collision with the scanner aperture. Radiopaque marks were placed on the medial and lateral borders of the tangential fields. All patients were scanned in spiral mode with slice width and thickness of 3 mm each, respectively. The lung and heart structures as well as irradiated areas were delineated on each slice and respective volumes were accurately measured. The treatment beam parameters were recorded and the digitally reconstructed radiographs (DRRs) were generated for the measurement of the CLD and analysis. RESULTS: Using CT data the mean volume and standard deviation of left and right lungs were 1307.7+/-297.7 cm3 and 1529.6+/-298.5 cm3, respectively. The magnitude of irradiated volume in left and right lung is nearly equal for the same CLD that produces different percent irradiated volumes (PIV). The left and right PIV lungs are 8.3+/-4.7% and 6.6+/-3.7%, respectively. The PIV data have shown to correlate with CLD with second- and third-degree polynomials; however, in this study a simple straight line regression is used to provide better confidence than the higher order polynomials. The regression lines for the left and right breasts are very different based on actual CT data. The slopes of regression lines for the left and right lung are 0.6%/mm and 0.5%/mm, respectively which is statistically different with thep value of 0.01. A maximum heart PIV of >3.0% is observed in 80% of the patients. The heart PIV is inversely correlated with gantry angle and weakly correlated with CLD. CONCLUSIONS: The CT-simulator provides accurate volumetric information of the heart and lungs in the treatment fields. The lung PIV is directly correlated to the CLD (0.6%/mm and 0.5%/mm for the left and right lungs). Left and right lungs have different volumes and hence, different regression lines are recommended. An additional 12% lung volume could be irradiated in the supraclavicular field. Heart volume is not correlated with the CLD. The heart PIV is associated to the beam angle. Heart volume may not be accurately visualized in a tangential radiograph; however, this can be easily seen in a DRR with contour delineation and can be minimized with proper beam parameters iteratively with a virtual simulator. Lung and heart PIV along with dose volume histograms (DVH) are essential in reducing pulmonary and cardiac complications.

Adult↗
PubMed1998

Use of the prone position in radiation treatment for women with early stage breast cancer.

PURPOSE: The prone position has been advocated for women with large pendulous breasts undergoing breast-conserving treatment with radiation therapy. However, there is no information in the literature regarding the coverage of the target volume with this technique. The purpose of this study was to evaluate the effectiveness of the prone treatment position in including at least the biopsy cavity with a 2-cm margin. METHODS AND MATERIALS: Eleven consecutive patients who underwent CT simulation in the prone position were included in this study. Patients underwent CT simulation in the prone position using a flat platform containing an aperture for the breast to hang through in a dependent fashion. CT slices were 5-mm thick taken at 3-mm intervals. The biopsy cavity was localized and outlined on sequential CT images using the surgical clips (when present) as well as the residual seroma. A 2-cm margin was included around the biopsy cavity to define the minimal target volume (mTV). Lateral fields were used for treatment planning. The beam arrangements were considered adequate if the mTV was totally included in the lateral fields. RESULTS: Median age of the patient population was 55 years. Bra sizes ranged from 36A-44DD. The majority of patients had mammographically detected T1 lesions. Median volume of the biopsy cavity was 48 cm3. Five of 11 (45%) patients underwent reexcision of the biopsy cavity, and 6 of 11 (55%) had surgical clips placed in the biopsy cavity. Overall, 8 of 11 (73%) patients did not have the entire mTV included in the lateral opposed tangential fields in the prone position. This was especially true in patients whose biopsy cavity extended down to the chest wall. There were no other clinical factors that could predict for the adequacy of coverage in the prone position. CONCLUSION: Special attention must be paid to the location of the surgical clips to determine the proximity of the biopsy cavity to the chest wall, or CT simulation should be performed to determine the exact location of the biopsy cavity prior to selecting patients with large pendulous breasts for treatment in the prone position.

Adult↗
PubMed1997

Results of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS).

PURPOSE: The role of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS) is controversial. In particular, there is little data for outcome with radiation in a group of patients comparable to those treated with local excision and surveillance (mammographic calcifications < or = 2.5 cm, negative resection margins, negative postbiopsy mammogram). This study reports outcome of conservative surgery and radiation for mammographically detected DCIS with an emphasis on results in patients considered candidates for excision alone. METHODS AND MATERIALS: From 1983 to 1992, 110 women with mammographically detected DCIS (77% calcifications +/- mass) and no prior history of breast cancer underwent needle localization and biopsy with (55%) or without a reexcision and radiation. Final margins of resection were negative in 62%, positive 7%, close 11%, and unknown 20%. The median patient age was 56 years. The most common histologic subtype was comedo (54%), followed by cribriform (22%). The median pathologic tumor size was 8 mm (range 2 mm to 5 cm). Forty-seven percent of patients with calcifications only had a negative postbiopsy mammogram prior to radiation. Radiation consisted of treatment to the entire breast (median 50.00 Gy) and a boost to the primary site (97%) for a median total dose of 60.40 Gy. RESULTS: With a median follow-up of 5.3 years, three patients developed a recurrence in the treated breast. The median interval to recurrence was 8.8 years and all were invasive cancers. Two (67%) occurred outside the initial quadrant. The 5- and 10-year actuarial rates of recurrence were 1 and 15%. Cause-specific survival was 100% at 5 and 10 years. Contralateral breast cancer developed in two patients. There were too few failures for statistical significance to be achieved with any of the following factors: patient age, family history, race, mammographic findings, location primary, pathologic size, histologic subtype, reexcision, or final margin status. However, young age, positive or close margins, and the presence of a mass without calcifications had a trend for an increased risk of recurrence. There were no recurrences in the subset of 16 patients who would be candidates for surveillance by Lagios' criteria. CONCLUSION: For selected patients, conservative surgery and radiation for mammographically detected DCIS results in a low risk of recurrence in the treated breast and 100% 5- and 10-year cause-specific survival. Improved mammographic and pathologic evaluation results in better patient selection and reduces the risk of the subsequent appearance of DCIS in the biopsy site. The identification of risk factors for an ipsilateral invasive breast recurrence is evolving.

Adult↗
PubMed1997

Dosimetric comparison of treatment planning systems in irradiation of breast with tangential fields.

PURPOSE: The objectives of this study are: (1) to investigate the dosimetric differences of the different treatment planning systems (TPS) in breast irradiation with tangential fields, and (2) to study the effect of beam characteristics on dose distributions in tangential breast irradiation with 6 MV linear accelerators from different manufacturers. METHODS AND MATERIALS: Nine commercial and two university-based TPS are evaluated in this study. The computed tomographic scan of three representative patients, labeled as "small", "medium" and "large" based on their respective chest wall separations in the central axis plane (CAX) were used. For each patient, the tangential fields were set up in each TPS. The CAX distribution was optimized separately with lung correction, for each TPS based on the same set of optimization conditions. The isodose distributions in two other off-axis planes, one 6 cm cephalic and the other 6 cm caudal to the CAX plane were also computed. To investigate the effect of beam characteristics on dose distributions, a three-dimensional TPS was used to calculate the isodose distributions for three different linear accelerators, the Varian Clinac 6/100, the Siemens MD2 and the Philips SL/7 for the three patients. In addition, dose distributions obtained with 6 MV X-rays from two different accelerators, the Varian Clinac 6/100 and the Varian 2100C, were compared. RESULTS: For all TPS, the dose distributions in all three planes agreed qualitatively to within +/- 5% for the "small" and the "medium" patients. For the "large" patient, all TPS agreed to within +/- 4% on the CAX plane. The isodose distributions in the caudal plane differed by +/- 5% among all TPS. In the cephalic plane in which the patient separation is much larger than that in the CAX plane, six TPS correctly calculated the dose distribution showing a cold spot in the center of the breast contour. The other five TPS showed that the center of the breast received adequate dose. Isodose distributions for 6 MV X-rays from three different accelerators differed by about +/- 3% for the "small" patient and more than +/- 5% for the "large" patient. For two different 6 MV machines of the same manufacturer, the isodose distribution agreed to within +/- 2% for all three planes for the "large" patient. CONCLUSION: The differences observed among the various TPS in this study were within +/- 5% for both the "small" and the "medium" patients while doses at the hot spot exhibit a larger variation. The large discrepancy observed in the off-axis plane for the "large" patient is largely due to the inability of most TPS to incorporate the collimator angles in the dose calculation. Only six systems involved agreed to within +/- 5% for all three patients in all calculation planes. The difference in dose distributions obtained with three accelerators from different manufacturers is probably due to the difference in beam profiles. On the other hand, the 6 MV X-rays from two different models of linear accelerators from the same manufacturer have similar beam characteristics and the dose distributions are within +/- 2% of each other throughout the breast volume. In general, multi-institutional breast treatment data can be compared within a +/- 5% accuracy.

Body Constitution↗
PubMed1997

Dose estimation to critical organs from vertex field treatment of brain tumors.

PURPOSE: Radiation management of intracranial tumors may require a noncoplanar vertex field that often irradiates the entire length of the body. In view of radiation related risks to the normal tissues dose estimation to the extracranial organs such as the thyroid gland, spinal cord, heart, and genitalia is performed for a vertex field. METHODS AND MATERIALS: A vertex field used clinically was reproduced on an anthropomorphic Rando phantom to measure radiation dose to various organs in the primary beam. Three photon beams (4, 6, and 10 MV), and two high energy electron beams (16 and 20 MeV) were used. Dosimetry was performed with an ion chamber sandwiched between phantom slices at the appropriate positions. All doses were normalized to the target dose at a depth of 5 cm. The effect of the head position was studied by rotating the gantry angle up to +/-20 degrees to mimic the extension and flexion of the head. Theoretical calculation was performed using an exponential best fit to the depth dose table to estimate the dose to various points and compare with the measured dose. RESULTS: The measured normalized dose to the cervical cord, thyroid, heart, and female and male gonads are 60, 36, 16, 2.5, and 1.6%, respectively, for a 6 MV photon beam. The dose from 4 MV and 10 MV are slightly lower and higher, respectively. Doses from electron beams are about a factor of 4-10 lower than those of the photon beams. The measured gonadal dose from the primary beam is <5% of the target dose for all energies used in the study. The actual value, however, is dependent on the body structure, length, and the posture of the patient. A +5 degree head flexion had little effect on the dose to the various parts of the body. The head rotations greater than +/-10 degrees produced relatively lower doses by a factor of 10(-2) to the organs at distances greater than 40 cm from the prescription point. The radiation doses to the different critical organs estimated from the fitted curves are lower than the measured doses up to 35%. CONCLUSIONS: When a vertex field is used for the treatment of the brain tumors, the entire axial length of the body is irradiated which adds to the integral dose. Unlike the scattered and leakage radiation, the primary dose to extracranial critical organs is greater for higher energies. For a 10 MV beam the ovary and testis at a distance of 80 cm and 90 cm may receive a dose of 4.2 and 3%, respectively, of the target dose. The gonadal dose could be quite significant if the entire treatment is delivered using a vertex field. For pediatric and smaller patients, dose to the critical organs at known distances could be estimated from the empirical equation obtained from the measured data. While the risk-benefit ratio is often evaluated and acceptable for treating malignant tumors, the long-term complications need thorough assessment in younger and curable patients. In view of radiation carcinogenesis and genetic burden, dose reduction to critical organs should be considered using a 3D planning system to arrange beams in other nonaxial planes and by considering electron beams for the vertex field.

Brain Neoplasms↗
PubMed1997

Effect of low-density lateral interfaces on soft-tissue doses.

PURPOSE: Doses at the interface between tissue and low-density inhomogeneities with the interface positioned perpendicular to the beam direction have been well studied. When the inhomogeneity lies parallel to the beam direction (i.e., a lateral interface), the resulting dose distribution is not as well known. Lateral lung-soft-tissue interfaces are common in many fields used to treat malignancies in the thorax region including tangential breast fields and anteroposterior fields for lung and esophageal cancer. The purpose of this study was to evaluate the dose distribution along lateral interfaces and to determine the implications for treatment. METHODS AND MATERIALS: A polystyrene and cork slab phantom was irradiated from the side to simulate treatment fields with lateral lung-soft-tissue interfaces. The beam was positioned with the isocenter in polystyrene and the field edge in cork. Cork slabs (0.6-2.5 cm) were used to simulate different thicknesses of lung between the field edge and the target volume. Measurements were made using a parallel plate ionization chamber. With the chamber position held constant, polystyrene slabs were added between the cork and the chamber to study the dose distribution in the interface region. Interface doses were studied as a function of the amount of cork in the field, field size, beam energy (6-18 MV), and depth. RESULTS: Doses in the interface region were lower by as much as 10% compared to doses in a homogeneous phantom. For a given cork width and field size, the magnitude of the underdose increased by several percent as the x-ray energy increased from 6 to 18 MV. The underdose at the interface was 5% for 6 MV and 8% for 18 MV X-rays with a 1-cm cork width. For a 2.5-cm cork width, underdoses of 2.5% and 3% at distances up to 2.5 and 4 mm lateral to the interface were observed for 6- and 18-MV X-rays, respectively. However, doses right at the interface were 1% greater for 6 MV and 3% less for 18 MV than doses in a homogeneous phantom. For a given cork width, the interface doses were not significantly dependent on field width but decreased by an additional 2-3% as the length decreased to 4 cm. Additional decreases were also observed when the measurement depth decreased to 3 cm. With a 1-cm width of cork in the field, a lateral distance of 3-4 mm from the interface was necessary to ensure doses of at least 98% of the homogenous dose with 6-MV X-rays. A lateral distance of 6-7 mm was necessary for 10- and 18-MV X-rays. CONCLUSION: Underdosing will occur in the soft tissues adjacent to low-density inhomogeneities. The magnitude depends primarily on the width of the inhomogeneity seen in the treatment field, but also on field size, depth, and beam energy. For treatment fields with a lateral lung interface, a segment of tissue approximately 3-4 mm thick for 6 MV and 6-7 mm thick for higher-energy beams may be underdosed. Lung widths of > or = 1.75 cm as observed on film will generally guarantee doses of at least 96% of those calculated with no inhomogeneity corrections. High-energy beams are often used to treat sites in the thorax or breast to improve dose homogeneity throughout the treatment volume. Potential underdosing due to the presence of lung should be considered and may require a decrease in beam energy or an increase in the margin between the target volume and the field edge to ensure adequate treatment.

Connective Tissue↗
PubMed1997

Patterns of dose variability in radiation prescription of breast cancer.

PURPOSE: Comparison of radiation outcome of various treatment protocols is difficult due to the variability of dose prescription. A retrospective analysis of the pattern and intercomparison of dose prescriptions is presented for the treatment of breast cancer. MATERIALS AND METHODS: To represent the clinical practice for breast irradiation with tangential fields, commonly used prescription points were chosen that lie on the perpendicular bisector of the chest wall separation (s) that represents the breast apex height (h). These points are located at 1.5 cm from the posterior beam edge, at the chest wall-lung interface (2-3 cm), at distances of h/3 and h/2, and at the isocenter. One hundred consecutive patients treated with intact breast following excisional biopsy were used in this study. For analysis, treatment planning was carried out without lung correction with a 6 MV beam for all patients, even though some of the patients were treated with high energy beams for dose uniformity. Dose distributions were optimized with wedges and beam weights to provide a symmetrical dose distribution on the central axis plane. The statistical analyses of the different parameters, s, h, maximum dose, and doses at various prescription points were carried out. RESULTS: The maximum dose (hot spot) in breast varied from +5% to +27% above the prescribed dose among the patient population. The hot spot was directly related to s, and appeared to be independent of h and the ratio h/s. Among 55%, 40%, and 5% of the patients, the magnitude of the hot spot was 5-10%, 10-15%, and >15%, respectively. Except for the magnitude of the hot spot, the doses at various prescription points were independent of the breast size. For a prescription point at h/3 or at the lung-chest wall interface, the dose variation within +/- 1% is observed for 90% of the patient population. On the other hand, the average dose variation is about +/- 3% among other protocols with dose prescription point varying up to the h/2 point. With the prescription point at the isocenter, an average and maximum variation of 4-5% and 11% were observed, respectively. The maximum dose inhomogeneity for some patients was significantly higher, i.e. up to +27% even without the lung correction. CONCLUSIONS: A wide variation in prescription dose is observed among the different treatment protocols commonly used in breast treatment. For a total dose of 46-50 Gy delivered at 2 Gy/fraction to the breast, the prescribed dose may vary between 50 and 55 Gy and the hot spot dose per fraction may range between 2.3 and 2.5 Gy depending on the protocol and breast size. Thus dose normalization at hot spot and the isocenter should be discouraged unless the total dose to the breast is modified. A uniform definition of dose prescription for breast treatment is greatly required for intercomparison of clinical data.

Breast Neoplasms↗
PubMed1997

Postmastectomy radiation: then and now.

With the increased use of doxorubicin-based chemotherapy, chemoendocrine therapy, and high-dose chemotherapy with autologous bone marrow transplantation or peripheral blood progenitor-cell reinfusion, the role of postmastectomy radiation in the treatment of stages II-III breast cancer has been challenged. Despite these therapies, 20% to 30% of patients with four or more positive nodes, primary tumor size > or = 5 cm, or pectoral fascia involvement will develop an isolated locoregional recurrence. Postmastectomy radiation decreases the incidence of locoregional recurrence to < or = 10% in these high-risk patients, and modifications in technique can minimize long-term cardiac mortality. A recent meta-analysis has demonstrated a decrease in breast cancer mortality of approximately 10% with postmastectomy radiation, which is similar to the effect of adjuvant systemic therapy in axillary node-positive patients. Future studies are needed to further define the subset of patients who will benefit from postmastectomy radiation and to more precisely quantitate this benefit.

Antineoplastic Agents↗
PubMed1996

The impact of tamoxifen on breast recurrence, cosmesis, complications, and survival in estrogen receptor-positive early-stage breast cancer.

PURPOSE: To evaluate the impact of tamoxifen on breast recurrence, cosmesis, complications, overall and cause-specific survival in women with Stage I-II breast cancer and estrogen receptor positive tumors undergoing conservative surgery and radiation. METHODS AND MATERIALS: From 1982 to 1991, 491 women with estrogen receptor positive Stage I-II breast cancer underwent excisional biopsy, axillary dissection, and radiation. The median age of patient population was 60 years with 21% < 50 years of age. The median follow-up was 5.3 years (range 0.1 to 12.8). Sixty-nine percent had T1 tumors and 83% had histologically negative axillary nodes. Re-excision was performed in 49% and the final margin of resection was negative in 64%. One hundred fifty-four patients received tamoxifen and 337 patients received no adjuvant therapy. None of the patients received adjuvant chemotherapy. RESULTS: There were no significant differences between the two groups for age, race, clinical tumor size, histology, the use of re-excision, or median total dose to the primary. Patients who received tamoxifen were more often axillary node positive (44% tamoxifen vs. 5% no tamoxifen), and, therefore, a greater percentage received treatment to the breast and regional nodes. The tamoxifen patients less often had unknown margins of resection (9% tamoxifen vs. 22% no tamoxifen). The 5-year actuarial breast recurrence rate was 4% for the tamoxifen patients compared to 7% for patients not receiving tamoxifen (p = 0.21). Tamoxifen resulted in a modest decrease in the 5-year actuarial risk of a breast recurrence in axillary node-negative patients, in those with unknown or close margins of resection, and in those who underwent a single excision. Axillary node-positive patients had a clinically significant decrease in the 5-year actuarial breast recurrence rate (21 vs. 4%; p = 0.08). The 5-year actuarial rate of distant metastasis was not significantly decreased by the addition of adjuvant tamoxifen in all patients or pathologic node-negative patients. Pathologically node-positive patients had a significant decrease in distant metastasis (35 vs. 11%; p = 0.02). There were no significant differences in cause-specific survival for patients receiving tamoxifen when compared to observation (95% no tamoxifen vs. 89% tamoxifen; p = 0.24). Similar findings were noted for pathologically node-negative patients. However, axillary node-positive patients receiving tamoxifen had an improvement in 5-year actuarial cause-specific survival (90% tamoxifen vs. 70% no tamoxifen; p = 0.10). Cosmesis (physician assessment) was good to excellent in 85% of the tamoxifen patients compared to 88% of the patients who did not receive tamoxifen. CONCLUSION: The addition of tamoxifen to conservative surgery and radiation in women with Stage I-II breast cancer and estrogen receptor positive tumors resulted in a modest but not statistically significant decrease in the 5-year actuarial risk of a breast recurrence. Tamoxifen significantly decreased the 5-year actuarial risk of distant metastasis in axillary node-positive patients and there was a trend towards improvement in cause-specific survival that was not statistically significant. Tamoxifen did not decrease the 5-year actuarial rate of distant metastasis in axillary node negative, patients and in this group, there was no improvement in cause-specific survival. Tamoxifen did not have an adverse effect on cosmesis or complications.

Adult↗
PubMed1996

Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast.

PURPOSE: To determine the 15-year outcome for women with ductal carcinoma in situ (DCIS, intraductal carcinoma) of the breast treated with breast-conserving surgery followed by definitive breast irradiation. PATIENTS AND METHODS: An analysis was performed of 270 intraductal breast carcinomas in 268 women from 10 institutions in Europe and the United States. In all patients, breast-conserving surgery included complete gross excision of the primary tumor followed by definitive breast irradiation. When performed, pathologic axillary lymph node staging was node-negative (n=86). The median follow-up time was 10.3 years (range, 0.9 to 26.8). RESULTS: The 15-year actuarial overall survival rate was 87%, and the 15-year actuarial cause-specific survival rate was 96%. The 15-year actuarial rate of freedom from distant metastases was 96%. There were 45 local recurrences in the treated breast, and the 15-year actuarial rate of local failure was 19%. The median time to local failure was 5.2 years (range, 1.4 to 16.8). A number of clinical and pathologic parameters were evaluated for correlation with local failure, and none were predictive for local failure (all P > or = .15). CONCLUSION: The results from the present study demonstrate high rates of overall survival, cause-specific survival, and freedom from distant metastases following the treatment of DCIS of the breast using breast-conserving surgery and definitive breast irradiation. These results support the use of breast-conserving surgery and definitive breast irradiation for the treatment of DCIS of the breast.

Adult↗
PubMed1995

Factors associated with a positive reexcision after excisional biopsy for invasive breast cancer.

BACKGROUND: Breast-conserving therapy followed by adjuvant radiotherapy represents an alternative to mastectomy as a treatment for invasive breast cancer. When excisional biopsy has been performed outside the parent institution, reexcision is often performed, with tumor being identified in 32% to 62% of the subsequent specimens. We analyzed not only the factors associated with a positive reexcision but also those factors associated with final surgical margins that are positive for tumor. METHODS: Between 1978 and 1991, 956 female patients with American Joint Committee on Cancer clinical stage I or II breast cancer were treated with breast-conserving therapy where a total of 420 patients underwent reexcision after an initial excisional biopsy. Several factors were analyzed to determine their association with a positive reexcision, the status of the final surgical margin, and the nature of the disease present within the reexcision specimen. RESULTS: Factors that correlated with a positive reexcision in both univariate and multivariate analysis were clinical tumor size, method of detection, the pathologic status of the axillary lymph nodes, and the histologic appearance. Those factors associated with finding invasive disease at the time of reexcision were clinical tumor size, clinical presentation, and nodal status. The single factor associated with finding residual in situ disease at the time of reexcision was histologic appearance of the primary tumor. A final positive margin was associated with method of tumor detection, age of the patient, and the presence of axillary lymph node metastases. CONCLUSIONS: The most significant factors associated with a positive reexcision are clinical tumor size, method of tumor detection, pathologic nodal status, and histologic appearance. Patients with larger tumors or those that are detected by physical examination, as well as invasive lobular carcinomas, may require a more generous initial resection to achieve negative surgical margins and avoid the likelihood of reexcision.

Adult↗
PubMed1993

The role of mastectomy in patients with stage I-II breast cancer presenting with gross multifocal or multicentric disease or diffuse microcalcifications.

PURPOSE: Women with Stage I-II invasive breast cancer who present with gross multicentric disease or diffuse microcalcifications have a significant risk of breast recurrence when treated with conservative surgery and radiation. The purpose of this report is to present the results of mastectomy in this group of patients. METHODS AND MATERIALS: Between 1982 and 1989, 88 patients with clinical Stage I-II breast cancer who presented with clinical and mammographic evidence of gross multicentric disease or diffuse microcalcifications underwent modified radical mastectomy. Median followup was 4 years for the 57 patients with gross multicentric disease and 5.6 years for 31 patients with diffuse microcalcifications. At the time of mastectomy, 42% of patients were found to have positive axillary nodes. Following mastectomy, 15 patients received post mastectomy radiation and 35 patients received adjuvant systemic chemotherapy. RESULTS: When compared to a group of 1295 patients with unifocal, Stage I-II breast cancer, treated with conservative surgery and radiation during the same time period, patients with gross multicentric disease and diffuse microcalcifications had a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease had a lower incidence of positive resection margins following mastectomy and patients with diffuse microcalcifications were younger. The 5-year actuarial risk of an isolated local-regional recurrence was 8% for patients with gross multicentric disease or diffuse microcalcifications and 7% for patients with unifocal disease. Patients with gross multicentric disease or diffuse microcalcifications and > or = 4 positive axillary nodes who did not receive post mastectomy radiation had an increased risk for local regional recurrence. There were no significant differences in the 5-year actuarial overall or relapse-free survival (88% and 73% gross multicentric disease, 97% and 86% diffuse microcalcifications and 90% and 79% unifocal disease), freedom from distant metastasis (76% gross multicentric disease, 90% diffuse microcalcifications, 86% unifocal disease) or incidence of contralateral breast cancer (10% gross multicentric disease, 13% diffuse microcalcifications, 8% unifocal disease) among the three groups. CONCLUSION: The present study demonstrates no increased risk of local-regional recurrence in patients with gross multicentric disease or diffuse microcalcifications undergoing mastectomy in contrast to the increased risk of breast recurrence in patients with gross multicentric disease undergoing conservative surgery and radiation. Indications for post mastectomy radiation include > or = 4 positive nodes or close or positive surgical margins. Despite a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease and diffuse microcalcifications have a 5-year actuarial overall and relapse-free survival comparable to a group of patients with unifocal disease treated with conservative surgery and radiation.

Actuarial Analysis↗